https://leader.pubs.asha.org/article.aspx?articleid=2683700Lessons from 6 Months of New Cognitive Treatment Procedure CodesSLPs faced challenges navigating two new codes for cognitive treatment. Here’s what we learned about implementation.2018-06-01T00:00:00Bottom LineNeela Swanson

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Bottom Line | June 01, 2018

Lessons from 6 Months of New Cognitive Treatment Procedure CodesSLPs faced challenges navigating two new codes for cognitive treatment. Here’s what we learned about implementation.

Payer use of and reimbursement for two new cognitive treatment procedure codes that went into effect in January have been inconsistent, creating administrative difficulties for speech-language pathologists as they adjust their claims-reporting to accommodate multiple coding options.

SLPs’ use of 97127 and G0515 has varied widely, depending on the payer, and continues to evolve as payers adjust their claims-processing systems and fee schedules. Here’s what we know six months after these codes went into effect. (But as always, SLPs shou ld check with each payer for confirmation of their policies related to evaluation and treatment of patients with cognitive disorders.)

This coding guidance applies primarily to outpatient billing. Some inpatient settings use CPT codes for administrative and productivity purposes, but not for billing. Each facility has its own criteria for tracking services and determining productivity, but these rules are separate from payment policy.

Medicare has implemented G0515 across all states, but other payers’ use of the code varies widely across the country.

The Centers for Medicare and Medicaid Services (CMS) created code G0515 specifically for use by the Medicare program. It is included in the Medicare Physician Fee Schedule and the list of codes eligible for billing under a therapy plan of care, commonly known as the “sometimes or always therapy list.” Medicare administrative contractors that have published local coverage determinations related to speech-language pathology or cognition have all replaced CPT 97532 with G0515.

Conversely, there is no such consistency among other payers. Each state Medicaid agency, private health insurance plan, and Medicare Advantage or Part C plan can choose either G0515 or 97127. For example, Ohio Medicaid has implemented CPT 97127, while Medicaid in Maine has opted to use G0515. Private health plans administered by Blue Cross Blue Shield (BCBS) have chosen 97127 more consistently, but use varies depending on the BCBS plan’s state.

ASHA contacted all state Medicaid agencies and major health insurance plans about the coding change in 2017, and received formal confirmation regarding coding for cognitive treatment from only two programs—UnitedHealthcare (a private health insurance plan) and Colorado Medicaid. UnitedHealthcare uses 97127; Colorado Medicaid uses G0515.

To complicate matters even further, some payers are still updating their systems and have not fully implemented either code. For example, California Medicaid was using CPT 97532 in the first quarter of 2018, and only recently updated its fee schedule to include G0515.

It is critical for SLPs to track which codes are being used by which payers, and to continue to check with payers to ensure they have the most updated information.

Practices and facilities are coping with the administrative challenge of multiple coding options—and payers’ slow implementation of coding changes—in different ways.

Smaller practices that do not see many patients or that bill a limited number of payers have more commonly opted to contact each payer directly to determine how it has implemented the code. Larger facilities that work with many different health insurance plans may choose to submit all initial claims for cognitive treatment using one code, and then track denials and adjust claims for specific payers accordingly. This practice, however, assumes that the facility has the necessary resources to absorb the cost of delayed payments.

It is critical for SLPs to track which codes are being used by which payers, and to continue to check with payers to ensure they have the most updated information.

The new codes do not change or expand payers’ coverage of cognitive treatment services.

Although cognitive treatment codes are new, payer policies regarding coverage of cognitive treatment have generally not changed. For example, some Medicaid and private health plans that did not previously recognize 97532 as a payable code also do not recognize G0515 or 97127 for payment.

If plans do cover cognitive treatment services, the new codes should be reported under the same general payer coverage guidelines. For instance, if a payer covers treatment for cognitive disorders related only to stroke or traumatic brain injury, the new codes do not expand covered diagnoses—and clinicians should bill the new codes to the payer only for the services covered under each patient’s specific benefit.

97127 and G0515 should not be billed on the same day as CPT code 92507 (speech, language, voice, communication treatment) for Medicare Part B (outpatient) services.

The National Correct Coding Initiative (NCCI) has updated its edit list and confirmed in a letter to ASHA that 97127 and G0515 should not be billed on the same day by the same clinician for the same Medicare Part B beneficiary.

The NCCI determines code pairs that may not be billed together on the same day, commonly referred to as CCI edits. State Medicaid agencies are also required to use CCI edits, but may modify them to meet their own programmatic needs. Other payers may also adopt CCI edits. A list of CCI edits for SLPs is available online. Check with non-Medicare payers (Medicaid, Medicare Advantage or Part C, or private health insurance) about their use of CCI edits.

SLPs should not switch to CPT 92507 to avoid the coding and coverage confusion related to cognitive treatment.

The conundrum over coding for cognitive treatment is a frustrating administrative burden and has disrupted timely payment. However, it is important for SLPs to work through those issues with payers. Changing coding to avoid a challenging payment or coverage situation could be considered fraudulent—and on audit, could attract scrutiny to billing, not only for cognitive treatment, but also for speech, language, voice and communication treatment reported with CPT 92507.

It may be appropriate to report CPT 92507 if the focus of treatment is cognitive communication and treatment goals are language-based. However, if treatment goals focus on cognitive function, such as memory, problem-solving or executive function, then SLPs should bill 97127 or G0515. Some payers may require SLPs to bill cognitive treatment under 92507, but these are exceptions.

Documentation should reflect activities and goals, and diagnosis codes should support the procedure code used.

Working with the payer directly to rectify coding confusion or inappropriate implementation can succeed, with perseverance.

In this early implementation phase, it has been common for a payer to use CPT 97127—an untimed code—without adjusting its fee schedule accordingly. Some practices have had success negotiating a revised rate by educating the payer about the change from a time-based to a session-based code.

Although working with a payer can be frustrating and time-consuming, clinicians need to be their own advocates. ASHA can provide information to help educate payers. Contact reimbursement@asha.org for ASHA’s support in working with a payer to correctly implement coding for cognitive therapy.